help with nursing diagnosis with AEB
- 0Jan 29, '13 by BandWhat do you see or hear or what the patient tells you that affirms the problem?
impaired physical mobility related to contractures as evidenced by limited ROM
ineffective airway clearance related to retained secretions as evidenced by rhonchi like (adventitious breath sounds)
acute pain related to surgical intervention as evidenced by patient verbal report of pain of 8 / 10
- 0Jan 30, '13 by LanesmamaI had trouble remember what was what when I first started, too!
Nursing diagnosis: Constipation
related to: (why)
as evidenced by: (proof that the constipation is a problem... can be something you see (objective) or something your patient tells you (subjective).
D(x): Constipation r/t (why) immobility due to recent surgery aeb (proof) distended, tender abdomen and pt. states, "I haven't moved my bowels in 5 days!"
Hope that helps!
- 0Jan 30, '13 by GrnTea, BSN, MSN, RNYou must use approved nursing diagnoses from NANDA, chosen because they meet your assessment findings. How do you know what to use? Well, in the NANDA-I 2012-2014, which every student should have even if the faculty forgot to put it on the bookstore list, free 2-day shipping from Amazon, you will find:
Nursing diagnosis: Definition
Defining Characteristics: (these are a list of potential causes of the diagnosis-- you only need one to support the diagnosis; note, you must have at least one related factor)
Related Factors: (these are things that could have caused the defining characteristics)
As an example:
Ineffective Self-Health Management: Pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals (page 161)
Defining characteristics: Failure to include treatment regimens into daily living; failure to take action to reduce risk factors; ineffective choices in daily living for meeting health goals; reports desire to manage the illness; reports difficulty with prescribed regimens
Related factors: Complexity of healthcare system; complexity of therapeutic regimen; decisional conflicts; deficient knowledge; economic difficulties; excessive demands made, e.g., individual, family; family conflict; family patterns of healthcare; inadequate number of cues to action; perceived barriers; perceived benefits; perceived seriousness; perceived susceptibility; regimen; social support deficit
As with all nursing diagnostic work, you must have assessment findings to support the diagnosis you make. Note that for many nursing diagnoses, the medical diagnosis may be included as a related factor, and therefore it is not correct to state that medical diagnosis has no part in nursing diagnosis. But nursing diagnosis is not DEPENDENT on medical diagnosis. Many of our diagnoses have nothing to do with the medical diagnosis; ours are based on human response to illness or injury. The example above, you see, can apply to anything-- a diabetic, heart disease, a new amputation, the parent of a child with leukemia, a mental health issue... Broaden your horizons. Get to where you need to be faster, think like a nurse. get NANDA-I and read a bit of it every night. You'll thank me later.Last edit by GrnTea on Jan 30, '13
- 0Feb 1, '13 by GrnTea, BSN, MSN, RNYou are supposed to know them because you get the book; beyond that, when you are licensed you will be held to the standard of using nursing diagnosis by your state licensing board and the ANA Scope and Standards of Practice.
Never mistake schooling for education. Get in the habit of taking responsibility for your education beyond what your schooling requires and you'll have a much more satisfying career.
- 0Feb 4, '13 by Esme12, BSN, RN Senior ModeratorLet the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
What is your assessment? What are the vital signs? What is your assessment. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.
The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.
Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.
Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.
Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition
Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.
Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE
- Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- Planning (write measurable goals/outcomes and nursing interventions)
- Implementation (initiate the care plan)
- Evaluation (determine if goals/outcomes have been met)
Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.
Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.
A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.
What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.
Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.
You need a good care plan book with the NANDA diagnosis listed with the definitions and characteristics. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition